paynewest insurance · web viewapplicant(s) hereby authorize the surety company and the agency to...
TRANSCRIPT
PAYNEWEST INSURANCE
PAYNEWEST INSURANCE
CONTRACTORS QUESTIONNAIRE PAGE 1
CONTRACTORS QUESTIONNAIRE Page 6
I. BUSINESS INFORMATION
Firm Name:
Contact Name:
E-mail Address:
Firm Address:
Phone:
Fax:
Website:
State of Incorporation:
Year Started:
Tax ID:
Is Your Firm Union?
|_| Yes |_| No |_| Both
Contracting Specialty:
LEED Project Experience:
|_| Yes
Number of Projects:
|_| No
Number of LEED Certified Employees:
Geographic Area(s) of Operation (Territory):
Type of Business:
|_| C-Corp. |_| Sub S. Corp. |_| Part. |_| Sole Prop. |_| LLC |_| LLP
# of Employees:
Office:
Field (min):
to (max):
Current Total:
Affiliations:
|_| AGC |_| ASA |_| ABC |_| CFMA
Other:
Certifications:
|_| 8a |_| HubZone |_| SDVOSB
Other:
II. OFFICER INFORMATION
List all owners, proprietors, partners, and officers of the firm:
#1
#2
Full Legal Name:
Full Legal Name:
Date of Birth:
% Owned:
Date of Birth:
% Owned:
Social Security #:
Social Security #:
Position:
Since:
Position:
Since:
Home Address:
Home Address:
Spouse Legal Name:
Spouse Legal Name:
Spouse Date of Birth:
Spouse Date of Birth:
Spouse Social Security #:
Spouse Social Security #:
#3
#4
Full Legal Name:
Full Legal Name:
Date of Birth:
% Owned:
Date of Birth:
% Owned:
Social Security #:
Social Security #:
Position:
Since:
Position:
Since:
Home Address:
Home Address:
Spouse Legal Name:
Spouse Legal Name:
Spouse Date of Birth:
Spouse Date of Birth:
Spouse Social Security #:
Spouse Social Security #:
Will all owners and their spouses provide full personal indemnification to the surety?
|_| Yes |_| No (explain below)
Explanation:
Is there a buy/sell agreement among the owners of the firm?
|_| Yes |_| No
Is this agreement funded by life insurance?
|_| Yes |_| No
PAYNEWEST INSURANCE
III. BUSINESS DETAILS
Has your firm or any of its principals ever petitioned for bankruptcy, failed in business, failed to complete a contract, or caused a loss to a surety? If yes, please attach an explanation.
|_| Yes |_| No
Is your firm or any of its owners or officers currently involved in any litigation? If yes, please attach an explanation.
|_| Yes |_| No
Percentage of the firm’s work for:
Government Owners:
%
Private Owners:
%
Other Contractors:
%
Trades you normally undertake with your own employees:
|_| None (Paper GC)
|_|
Percentage of the firm’s work normally subcontracted to others:
%
Trades you normally subcontract:
Sub bonding policy:
Preferred job size range:
$
to
$
Number of jobs at a time:
Largest cost to complete backlog:
$
Year:
Number of jobs:
Largest job expected during the next year:
Largest backlog expected during the next year:
Expected annual volume this current fiscal year:
Next fiscal year:
Do you lease equipment?
|_| Yes |_| No
Type of lease:
Terms of the lease:
IV. FINANCIAL INFORMATION
Name of CPA Firm:
Fiscal Year End:
Contact Name:
E-mail:
Company Address:
Company Phone:
Fax:
Web Site:
On what basis are taxes paid?
|_| Cash |_| Completed Job |_| Accrual |_| % of Completion
On what basis are financial statements prepared?
|_| Cash |_| Completed Job |_| Accrual |_| % of Completion
On what level of assurance are financial statements prepared?
|_| CPA Audit |_| Review |_| Compilation
How often are internal financial statements prepared?
|_| Annually |_| Semi-Annually |_| Quarterly |_| Monthly
How are bills paid?
|_| Discounts taken as offered |_| Prompt within payment terms |_| Late, within
days of due
Any material troubled A/R? |_| No |_| Yes
Explain:
Changes to the balance sheet since last fiscal year end (contributions, distributions, loans, material asset buys or sells, financing, etc.):
Do you have a full-time accountant on staff?
|_| Yes |_| No
Name:
Staff accountant professional designations:
|_| CPA |_| CCIFP
|_| Other:
Accounting Software:
Estimating Software:
Job Cost Software:
V. BANK INFORMATION
Name of Bank:
Address:
Contact Name:
Phone:
E-mail:
With this Bank Since:
Relationship currently includes:
|_| Deposit accounts |_| Revolving line of credit |_| Term loans
Line of Credit (LOC) Year Opened:
Amount:
$
Line Expires:
LOC – |_| Unsecured |_| Secured By:
LOC – Special Terms or Sublimits:
Other Bank(s) Used and Purpose:
VI. EXPERIENCE & REFERENCES
Previous Bonding Companies:
Name:
Dates:
Reason for leaving:
1
2
3
Have you ever been turned down by a surety?
|_| Yes |_| No If yes, why?
Largest Completed Contracts (largest first):
Job Name:
Job Name:
City, State:
City, State:
Contract Price:
Contract Price:
Gross Profit:
Gross Profit:
Date Completed:
Date Completed:
Bonded?:
Yes |_| No |_|
Bonded?:
Yes |_| No |_|
Contract Name:
Contract Name:
Firm:
Firm:
Phone:
Fax:
Phone:
Fax:
E-Mail:
E-Mail:
Project Description:
Project Description:
Job Name:
Job Name:
City, State:
City, State:
Contract Price:
Contract Price:
Gross Profit:
Gross Profit:
Date Completed:
Date Completed:
Bonded?:
Yes |_| No |_|
Bonded?:
Yes |_| No |_|
Contract Name:
Contract Name:
Firm:
Firm:
Phone:
Fax:
Phone:
Fax:
E-Mail:
E-Mail:
Project Description:
Project Description:
Job Name:
Job Name:
City, State:
City, State:
Contract Price:
Contract Price:
Gross Profit:
Gross Profit:
Date Completed:
Date Completed:
Bonded?:
Yes |_| No |_|
Bonded?:
Yes |_| No |_|
Contract Name:
Contract Name:
Firm:
Firm:
Phone:
Fax:
Phone:
Fax:
E-Mail:
E-Mail:
Project Description:
Project Description:
Major Suppliers (largest volume first):
Name:
Products:
Phone:
Fax:
Contact name:
Last used:
1
2
3
4
5
Major Trade Subcontractors, or Contractors If You Are a Trade Contractor (largest volume first):
Name:
Trade:
Phone:
Fax:
Contact name:
Last used:
1
2
3
4
5
Specialty Trade Subcontractors:
Name:
Trade:
Phone:
Fax:
Contact name:
Last used:
1
2
3
III. KEY PERSONNEL
Additional Key Personnel:
Name:
Designation(s):
Position:
Birth Year:
Years Experience
Total Years
At This Company:
Experience:
1
2
3
4
5
IX. LIFE INSURANCE INFORMATION
Life Insurance in Effect on Officers or Key Personnel:
Insured:
Beneficiary:
Death Benefit:
Insurance Company:
1
2
3
4
X. BUSINESS INSURANCE INFORMATION
Staff Risk Manager:
Designations:
|_| AFSB |_| CPCU |_| CRIS |_| Other:
Insurance Broker/Agency:
City/ State:
Agent’s Name:
E-mail:
Phone:
Fax:
Key Expiration Dates:
XI. SUBSIDIARIES AND AFFILIATES
Subsidiaries and Affiliates of the Applicant Firm:
Firm name:
Ownership/Relationship:
Type of Business:
FEIN:
Cross/Corp.Indemnity?
1
|_| Yes |_| No
2
|_| Yes |_| No
3
|_| Yes |_| No
4
|_| Yes |_| No
5
|_| Yes |_| No
Remarks:
XII. ATTACHMENTS
|_|
Copies of the last three fiscal year-end financial statements including work in progress and completed contract schedules.
|_|
Current interim financial statement and work in progress report if fiscal statement is over six months old.
|_|
Current personal financial statement for all indemnitors.
|_|
Bank Line of Credit Agreement.
|_|
Business Plan.
|_|
Federal Tax Returns.
|_|
Company – years:
|_|
Personal – years:
|_|
Buy / Sell Agreement.
|_|
Specimen copy of Subcontract Agreement.
|_|
Certificate(s) of Insurance (all lines carried).
|_|
Resumes of owners / key employees.
|_|
Brochure and/or Letters of Recommendation about the accomplishments of your firm.
|_|
Other: please describe below under “Additional Remarks.”
Applicant(s) hereby authorize the Surety Company and the Agency to make such pertinent inquiry as may be necessary from business and personal credit reporting agencies, financial institutions, persons, firms, and corporations in order to confirm and verify information referred to or listed on this application.
This questionnaire must be signed by an owner or officer of the company for which bonding is being requested.
Name of Firm:
Completed By:
Title:
Signature:
Date:
Additional Remarks: